Global Authoritative Drinking Guidelines on Moderation: Understanding Potential Risks and Benefits for the Individual and Public at Large

At the center of the ongoing social policy debate is the fundamental concern that the public be made fully aware of the risks of alcohol abuse. Experts emphasize that a better understanding of the potential risks and benefits of drinking will reinforce the sensible and responsible consumption of the individual and the public at large. This document is intended to reinforce the importance of sensible consumption for those who choose to drink by giving an overview on some of the most prominent authoritative statements from around the globe.*

Taking a close look at public health policy positions on alcohol in the US and abroad reveals interesting trends on what experts agree on and what they believe the public should be told. Most of the reviews are done by distinguished panels of experts often appointed by the government to review both the biomedical and psychosocial evidence. In fact, while most guidelines acknowledge the developing scientific consensus on moderate drinking and a reduced risk of coronary heart disease, the overall messages remain cautious and generally non drinkers are advised not to start drinking. Overall, the messages differ especially with respect to the discussions on any potential health advantages and the general advice on women’s health, underage drinking, and the elderly.

While at first glance, official moderation messages are much more positive than even ten years ago, it is increasingly apparent that policy bodies prefer to err on the side of caution because there is no clear scientific finding that can uniformly apply to every segment of the public. Furthermore, guidelines acknowledge that while there may be certain benefits, these are mainly evident in middle-aged individuals and need to be adequately weighed against certain risks. Many public health policy leaders stress that these facts should be highlighted and that people should be urged to obtain more individual advice from their physician or healthcare provider rather than relying on broad public messages.

The following excerpts from some of the major international moderation guidelines offer an overview of current official alcohol-related policy around the globe.*

THE DIETARY GUIDELINES FOR AMERICANS

The Dietary Guidelines for Americans are published every five years by the Departments of Agriculture and Health and Human Services with the most recent edition released in 2000 but a revised one to be upcoming in late 2004 or early 2005. The alcohol guidelines are presented as part of several nutritional messages intended to foster healthy lifestyles and eating patterns by emphasizing, “Eating is one of life’s greatest pleasures…you can enjoy all foods as part of a healthy diet as long as you don’t overdo it on fat, sugars, salt, and alcohol.”

The alcohol guideline not only outlines the risks of misuse but also some of the potential benefits from moderation and emphasizes the following three messages in the “Advice for Today” section:

· If you choose to drink alcoholic beverages, do so sensibly and in moderation.

· Limit intake to one drink per day(14g) for women or two per day for men, and take with meals to slow alcohol absorption.

· Avoid drinking before or when driving, or whenever it puts you or others at risk.

The message also cautions about additional calorie intake from alcohol and defines a drink as a 12 oz of regular beer, 5 oz of regular wine or 1.5 oz of 80 proof distilled spirits. Groups of individuals “who should not drink” include the young, the elderly, pregnant women, and those who operate machinery or take medication. Different from any other nation’s guidelines, the US message also states, “Risk of alcohol abuse increases when drinking starts at an early age.”

The lead paragraph warns about abuse and several potential health risks by underscoring, “Excess alcohol alters judgment and can lead to dependency and a great many other serious health problems. … Even one drink per day can slightly raise the risk of breast cancer.” In fact, any amount over the moderation definition is portrayed as potentially increasing the risk of several social and medical problems such as violence and high blood pressure.

At the same time, the potential positive effects are presented in the following way, “Drinking in moderation may lower the risk for coronary heart disease, mainly among men over age 45 and women over age 55. However, there are other factors that reduce the risk of heart disease including a healthy diet.” In this context it is further explained, “Moderate consumption provides little, if any, health benefit for younger people.” The concluding sentence on the subject of moderate consumption and health also cautions, “Some studies suggest that older people may become more sensitive to the effects of alcohol as they age.

In summary, while it is significant that messages on the potential health benefits associated with alcohol are highlighted in the Dietary Guidelines for Americans, it should be recognized that their mention is still very limited. However, these Guidelines are very unique in that the importance of sensible consumption with meals and as part of a well balanced diet is underscored. Other important US sources on drinking and health include recommendations by the National Institute on Alcohol Abuse and Alcoholism as well as public health groups such as the American Heart Association. (See table III)

UK SENSIBLE DRINKING GUIDELINES

The UK Sensible Drinking Guidelines were published in 1995 by an appointed intergovernmental group and are also being revised in the near future. These guidelines do not address any diet or lifestyle issues but they were designed as a review of medical evidence on alcohol” to develop alcohol use policies” that foster responsible non abusive behaviour.

Like the US Dietary Guidelines message, the UK Sensible Drinking Guidelines caution about abuse and explain who should not drink for both medical and social reasons. The guidelines also address the “possible risk of breast cancer” but do not specify abstention for pregnant women or those who are trying to conceive ( one or two units of 8g once or twice a week is deemed safe). On the other hand, the guidelines provide more detailed advice for individual situations. The specific messages strongly discourage binge drinking, recommend drink-free episodes and provide advice on drinking patterns. For example, they suggest possible changes in drinking customs for those who do not drink, those who drink very little, or are in an age group with a high risk for coronary heart disease.

In the UK levels of alcohol consumption “ unlikely to cause health damage “ are defined as 3 to 4 units (8g) per day for men , and 2 to 3 units per day for women. The UK message is unique in that it also gives a guideline or limit for weekly consumption, which are 21 units per week for men and 14 units per week for women...

In line with the US Dietary Guidelines, it is emphasized that there are some people who on medical grounds should not take up drinking as they can “make other changes to their lifestyle to lower the risk of coronary heart disease and improve their health in general.”

With respect to moderate consumption and health, all cause mortality is noted to be ‘at its lowest at modest drinking levels (at about one unit a day for men and women).’ In addition, a maximum health advantage of between one and two daily units is noted, and it is emphasized that a significant health risk will not accrue up to four units a day for men and three units a day for women. The guidelines also discuss that “the health benefits are more evident from regular daily drinking.” Specifically, men over age 40 and postmenopausal women are emphasized as recipients of a “significant health benefit in terms of reduced coronary heart disease mortality and morbidity.” Furthermore, the guidelines explain that middle aged or elderly non-drinkers or infrequent drinkers and especially those at risk for heart disease “may wish to consider the possibility that light drinking may be of benefit to their overall health and life expectancy.”

In summary, the UK guidelines are much more specific in addressing potential positive health outcomes with respect to moderate consumption. Most noteworthy, the Sensible Drinking Guidelines clearly suggest that for certain individuals; the benefits of moderation may outweigh the benefits of abstinence. They are also unique in that they provide both daily and weekly drinking limits for men and women.

THE AUSTRALIAN DRINKING GUIDELINES

In 2003, the Australian National Health and Medical Research Council released comprehensive “Drinking Guidelines.” These provide more comprehensive messages for the general population than either the US, UK or Canada. It is explained that the guidelines are intended to “provide Australians with knowledge and understanding that will enable them to enjoy alcohol, if they choose to drink, while avoiding or minimizing harmful consequences.” This overall opening message reflects a positive and balanced attitude that is further underscored by the statement, “Alcohol is widely used and enjoyed throughout our society, and for many people it forms part of an enjoyable and generally healthy lifestyle that includes good diet and exercise.”

The first guideline of 12 in-depth messages states, “Everyone who drinks alcohol should control their pattern of drinking to minimize both longer-term and short-term risks.” In addition, the guideline states, “To minimize risks and gain benefits in the long-term” men should not exceed an average of four standard drinks (10g) per day or 28 drinks a week and women should not drink more than two drinks a day or 14 standard drinks per week.

As in the UK, the Drinking Guidelines in Australia give both daily and weekly limits. Furthermore, men and women are also advised to have one to two alcohol-free days a week, which is not addressed in the US guidelines but advised in the UK guidelines.

Along the lines of other official guidelines, the report also highlights, “The protection that alcohol provides against heart disease is of importance only for people in age groups where heart disease is a risk, generally from about age 40 onward.” With respect to cancer it is emphasized, “There is clear evidence that alcohol is associated with an increased risk of cancer overall…. In particular, further research is needed to clarify the possible role of alcohol in relation to breast and bowel cancer.” However, different from any other official message, it is explained that there may be lower risks observed for certain cancer types if alcohol is taken with meals.

The report encourages responsible drinking, warns against drinking when undertaking activities that involve risk, and details certain groups that should not drink or who should use caution similar to other governmental guidelines. In contrast to other governmental statements, there are more detailed recommendations related to the elderly and the young who are urged to drink rather less than the general limits if they choose to drink at all. In sharp contrast to any other guidelines, the issue of underage drinking is addressed with the statement,” To become responsible adult drinkers, a gradual supervised introduction to alcohol is recommended.” In addition, pregnant women are advised not to drink or to “reduce their drinking to a minimum” as in the UK’s advice.

In summary, the Australian Guidelines provide the most specific recommendations for certain groups and discuss both the potential risks and benefits in much more detail than the US Dietary Guidelines. However, in contrast to the UK Guidelines, non drinkers are not encouraged to start drinking to gain any potential health benefits even if they were at risk for heart disease. Most significantly, the guidelines show a more open approach on how to deter underage drinking problems.

THE CANADIAN LOW RISK DRINKING GUIDELINES

The Canadian Low Risk Drinking Guidelines were endorsed by the Addiction Research Foundation and the Canadian Center on Substance Abuse in 1997. These alcohol guidelines were developed for health promotion in the general population and are specifically intended to assist physicians in providing best advice to individuals.

The Low Risk Drinking Guidelines “express current best advice about the health benefits and negative effects of alcohol use.” The different risks and benefits from moderate consumption are explained in similar ways to other governmental guidelines and it is stated that “men and women consuming up to 14 and 9 standard drinks per week, respectively, have a lower risk of early death than abstainers.”

One standard drink contains 13.6 grams of ethanol. Furthermore, it is explained that alcohol “has a protective effect over a wide range of intakes” but when abused “benefits are counterbalanced by increased risks of other chronic conditions and injuries.”

Additional advice in a slightly modified guideline has been endorsed by the Canadian Centre on Substance Abuse. In line with the Australian Guidelines, not increasing alcohol consumption for abstainers or infrequent drinkers and reducing risk of dependence by abstaining one day a week is recommended. The guidelines also explain, “In certain circumstances and for certain individuals, the use of alcoholic beverages is contraindicated.” They include this cautious or non drinking advice for those who are pregnant, have certain physical or physiological illnesses, take medications, operate vehicles or machinery, are unable to control drinking, are responsible for public order or safety, or are legally prohibited from drinking such as underage people. These guidelines also emphasize the general rule of no more than two standard drinks (13.6g) a day.

The Canadians stress, “People considering increasing their drinking for any health reasons should consult their physician before doing so.” This is in keeping with the general message that individuals should not drink to “reduce their risk of health problems,” which is strikingly different from the UK advice.

In summary, the Canadian Guidelines are unique in that the important role of the physician or health care provider in giving advice to individuals is emphasized. While these guidelines in no way recommend drinking for non drinkers for potential health benefits, they clearly acknowledge that some individuals should be given advice on the subject.

THE CHALLENGE OF VARIOUS DEFINITIONS OF MODERATION

To date the above guidelines are the most comprehensive in the world and have been acknowledged by major research and policy organizations. There are around a dozen additional countries that provide authoritative definitions of moderation. However, all these differ in their advice on the most appropriate drink sizes and unit messages to the public. (See table I and II)

When moderate drinking guidelines are approached in a standardized way with respect to ethanol content, several interesting differences emerge. For example, a drink in the US is 75% larger than a drink in the UK. When the respective upper limits are compared, the sensible consumption limits are much higher in the UK. Most strikingly, the limits “deemed safe” for women are 70% higher and for men are 17% higher than those in the US. The Australian limits are about 40% higher for both women and men.

Therefore, research and policy leaders have stressed that socially responsible education messages need to highlight the appropriate drink sizes and units for a particular population. Ultimately, that may also hold true for any of the health related messages which may also vary due to cultural differences.

SUMMARY PERSPECTIVE

In conclusion, public health and nutrition policy-related positions on alcohol are much more favorable than only a decade ago in that the differences between use and abuse are acknowledged. Most significantly, moderation guidelines discuss certain health benefits but caution about individual differences, women’s health concerns, as well as effects on the elderly and underage individuals. Except for the UK guidelines, messages around the globe do not present the option for a non drinker (at risk for coronary heart disease) to start drinking for health reasons and overall it is becoming evident that healthcare providers will be increasingly urged to address these health issues with their patients.

While guidelines around the world may differ in certain respects, they all are cautious because of fears that incomplete or too favorable messages may be misleading or encourage abuse. Governmental moderation guidelines may become more complicated as science more narrowly specifies different alcohol effects for different population groups and individuals. We can foresee that all these issues will be debated over the months and years to come as positions in several countries will be revisited.

As the moderation guidelines debate moves forward it appears to be most responsible to support education messages that emphasize an overall healthy diet and lifestyle for those adults who choose to enjoy moderation and tailor these messages so that they are in line with each country’s official guidelines and statements. AIM has long expressed concerns about alcohol misuse and bases all its advice around sensible drinking messages. Towards this end, AIM’s Executive has worked with several members of its Social, Scientific and Medical Council to prepare a draft “Science and Social Responsibility Education Message” that can be viewed on the Gateway site at www.aim-digest.com